Division of General Pediatrics Clinical Consult

Discussing teenage sexual behavior during annual visits

The topic of sexual activity is only discussed during 65 percent of primary care physicians’ annual visits with adolescents, according to a recent study in JAMA Pediatrics. During those visits, which typically last between 15 and 20 minutes, conversations about sex exceeds 35 seconds only 35 percent of the time, the study shows.

Romi Webster, MD, MPH, a pediatrician at Boston Children’s Hospital, is not surprised by the findings. “If a patient comes in with something she wants to discuss, or if the parents have an issue, we tend to focus on that issue,” she reports. As a result, specific concerns like acne or sports injuries can take up most of the meeting, leaving little time to discuss other important matters, like sexual health.

Despite the time constraints, Webster is “worried” about a missed opportunity when physicians don’t have enough time to discuss sexual behavior during annual visits with adolescents. “With teenagers, a lot can happen in a year,” she states, “so it’s important that we spend time on sexual issues to provide education and support and establish that sexual health is a part of overall health.”

About their study’s findings, the authors note that “physicians are missing opportunities to educate and counsel adolescent patients on healthy sexual behaviors and prevention of sexually transmitted infections and unplanned pregnancy.”

To help ensure sexual health is addressed at an annual visit, Webster recommends that PCPs incorporate a pre-visit screening that asks teenagers about health and safety issues, including issues related to sex. Information collected through these screenings can identify problem areas and guide the conversation during the visit.

Eliciting the parents’ concerns in a separate pre-visit screening also can “lead to better discussions and help the provider prioritize,” she says. These pre-screenings also communicate to parents and teenagers that sexual health is part of overall health and will be discussed in a confidential manner during visits—even if there’s “nothing going on,” Webster states.

To help with these discussions, physicians can rely on a number of tools. For example, Webster recommends a tool called HEEADSS (Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression and Safety), which provides guidance for addressing a range of health and safety topics with teens.

Webster offers a few tips for PCPs on getting the most out of their limited time to discuss sex with their teenage patients:

Create a safe space – “At every opportunity, but especially at annual visits,” Webster says that both patients and parents should be assured that the conversation must remain confidential. But, she says, topics related to sexual health can be addressed best “when parents are out of the room and kids are comfortable.”

Normalize behaviors – Webster says it is important for PCPs to explain to teens that “it is completely normal for them begin to have thoughts, feelings and concerns about sex.” Just as important, she says, is to “let teenagers know that they have a chance to make decisions about sexual activity—good decisions, healthy decisions, lower-risk decisions.”

Focus on health – Webster suggests that PCPs “keep conversations within the context of overall sexual health, which encompasses both emotional and physical health.” Infections, diseases and the risk of pregnancy are important physical health concerns that must be fully explained. However, issues of emotional health are just as important. PCPs to discuss “how sex fits into your larger life” and to address issues of “self-confidence, self-respect and self-worth,” urges Webster.

Be a source of good information – Teens, Webster asserts, get a lot bad information about sex. “I still have kids asking me if it’s true that you can’t get pregnant the first time you have sex or if you can get pregnant from toilet seats,” she reports. PCPs, she says, should offer themselves as sources of honest, clear information about sexual activity. In addition, she says that a number of helpful books are available to explain sexual issues to teens. The book The Care and Keeping of You and the websites Young Men's Health and The Center for Young Women's Health are “great resources,” she says.

Follow up – “If you have someone who is in need of more discussion about sexual health than is possible at their annual phsyical, find something to bring them back for a follow-up visit,” Webster advises. For example, she says that a teen who has been prescribed a medication or treatment can be asked back for a follow-up and the unrelated sexual issue can be addressed during that meeting. Tell the patient “I’m going to bring you back to talk about this issue. These are important decisions you’re making.”

In agreement with Webster’s recommendations, the study’s accompanying editorialist, Bradley O. Boekeloo, ScM, PhD, of the University of Maryland School Of Public Health, College Park, writes, “Overcoming barriers to physician-adolescent discussion about sexual health may require multitiered infrastructure supports. … A new primary care vision is needed to accommodate a range of sexual health topics, effective patient risk assessment and education practices, and multiple levels of primary care supports.”

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